The reason that I become interested in the evaluation of augmentation was based upon my own experience with this issue.

When I first joined the discussion board, I had just been diagnosed and had begun treatment with pramipexole. I was still in the "happy" period when pramipexole had completely erased the issues that I had been having with severe WED for about six years. It seemed like a miracle "cure". But in my welcome to the board summary, the moderators suggested that I might be augmenting based upon my description of symptoms before I had taken even my first DA. Unfortunately, after only a few weeks on pramipexole, I had to move from 0.25mg to 0.375 mg to maintain control. After nine months I needed to move up to 0.5 mg and knew that this meant trouble. My doctor (at that time) decided to switch me from pramipexole to a 2mg Neupro patch and gabapentin, which are still working reasonably well.

As I investigated augmentation a but further, I found that my base symptoms before treatment with an AD were going to make diagnosis of augmentation very difficult. The international questionnaire for evaluating augmentation has six questions, which can be summarized as:

1. Loss of effect of medication, evidenced by shorter benefit at night and needing higher doses2. Symptoms start earlier in the day3. Symptoms begin to involve other body parts4. Symptoms develop pain when pain was not present before5. You start developing sleepiness during the day that is separate from inadequate sleep6. Increasing loss of control of WED despite use of DA as scheduled.

Since my pre-DA symptoms already involved most of my body and were active 24/7, that meant that I could not use questions 2 and 3 and that question 1 would be more difficult to answer (other than needing higher dose). That only left three or four questions, which invalidating the scoring process for the questionnaire.

So, my take on all this is that diagnosis of augmentation is even less straight forward than the diagnosis of WED, which we all know can be difficult. A diagnosis of augmentation will quite probably involve a give-and-take discussion between you and your physician.

For my part, I know that eventually I am going to start showing signs of augmentation on Neupro. However, as Dr Allen stated in his webinar on augmentation (available to WED Foundation members at http://www.rls.org/members-only%20webinar), augmentation is something that can develop gradually over time. I have therefore started keeping a WED journal to track both my sleep and my use of medication. I review this and will begin looking for trends before I visit with my doctor so that I will have facts to share with him when the time comes rather than a vague description of my condition that simply leaves too much room from error (his to underestimate my condition and mine to overestimated any seeming increases in my symptoms).

The journal has already paid dividends for me. I went through the data and found that my breakthroughs were occurring on a regular 14 day basis. Turned out that those were the days when my Neupro patch was applied to the front of my right shoulder. I am severely right handed and remembered that the patch was usually starting to come off the next morning. I have been able to fix that my moving the application site just a bit so that the patch isn't having to undergo the 3D twisting that it saw on the "normal" application site.

Hey Guys---very imformative... I was on requipp for 3 years upto 2mg... I seem to be always tired.. Wear cpap and neck and shoulder pains however I got off the requipp to try gabapentin and that was a terrible trip... The doc has me back on requipp titrating back upto 1mg... Should I try the patch again? Some of those sysmptoms did sound like mine... The doc wants me to try loratab/requipp combo or even maybe methadone... My head feels like it wants to explode since i probably came off the gabapentin too quickly too supervised by the doctor....I'm concerned.... legs were kicking last night around 3am--- couldnt go back to sleep...

crazy joe wrote:Hey Guys---very imformative... I was on requipp for 3 years upto 2mg... I seem to be always tired.. Wear cpap and neck and shoulder pains however I got off the requipp to try gabapentin and that was a terrible trip... The doc has me back on requipp titrating back upto 1mg... Should I try the patch again? Some of those sysmptoms did sound like mine... The doc wants me to try loratab/requipp combo or even maybe methadone... My head feels like it wants to explode since i probably came off the gabapentin too quickly too supervised by the doctor....I'm concerned.... legs were kicking last night around 3am--- couldnt go back to sleep...

Depends on your answers to these questions:

1. What was your initial dose of ropinerole?2. How much was your final dose or ropinerole?3. Were your symptoms much worse or did they start earlier when taking ropinerole? 4. Did you ever try a different dopamine agonist - rotigotine, pramipexole?

My physician could not say for sure if what I was experiencing was augmentation. I have not been able to link especially bad attacks to any particular factor (coffee, alcohol, presence or absence of exercise, etc.). But I seem to be getting attacks more frequently and they are now requiring two doses of clonazepam (0.5 mg) to bring them under control. I've tried other medications and not found them to be any more effective than clonazepam, and I've been taking it at this level for 25 years without having to increase it - until now. Also, now the symptoms start in my chest and only travel to my legs when they become severe. A sense of vibration in my chest happens pretty much every time I sleep, even for a nap. I recently read about Van Leuwenhoek's disease and am wondering if there is any connection between that and WED? My chest symptoms sound identical to those of Van Leuwenhoek's.

Augmentation is believed to only occur with the use of the dopamine agonist drugs (pramipexole, ropinrole and rotigatine) and possibly Tramadol. The fact that you have been successfully using clonazepam for so long might be an indication that rather than augmentation, you might want to consider that maybe what you are experiencing is a natural progression of the disease.